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FILE COPY <br /> San Joaquin County �� <br /> Environmental Health Department APR 2 6 2006 SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA TRWR MITIGATION <br /> j f MENT HEALTH <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.o <br /> �>v��T/SERVI UNIT IV /�OU <br /> CES <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location WCS� ��`i f Cross Street W. 6"'^k Lmc it (Idc Assessors man UA r OG <br /> CC 11 y `1 Zip KUN// Parcel# T <br /> OwnerPROPERTYal 7o vl)n 6-- 161'D K RA: C4"" �,VC.. � {z�� ( Z <br /> Owner yAddress City �f�-f` Zip 9 SZ`�5 Phone# o9 <br /> Ca �°`de I�r 2. ,Me ( Ct S7y2 7175-10 Z�- 1l6 9 <br /> C-57 Contractor S Address 3�� C- �.'rC Q City Low w0 Zip`s Lic# Phone# 9(6) b <br /> Consultant/Sub Cntr S�� AddressU4k A" Z/City $LICr�^Li' c# N Phone#_(YO <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-A ER,OTHER*) 0 DESTRUCTION (choose type below) <br /> -SOIL BORING# 2 �� "�`�S P""` OVER-BORE. DIAMETER <br /> 0 WELL# q� PRESSURE GROUT <br /> *Other / GROUT SPECIFICATIONS <br /> COMMENTS: <br /> 4Z A <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE C- 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION ArAIR HAMMER/DRIVEN CASING THICKNESS n/A TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: AIA <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 2 S ! TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE ffPUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ,B'SOIL BORING J144AND AUGER GROUT SPECIFICATIONS Ne-0.+ cc--t— <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH Z s-f 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED AA (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certi that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> CountyOri es, Rules and R gulations, and all applicable California <br /> /?State <br /> / Laws.1 �A <br /> Signed Title/Company (�CGCQ��1/J;4 AG <br /> Print Name t°� Date lase <br /> DEPARTM NT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADD SS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued a Area D6r <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> I)/ M46 Z - SR# <br /> C-57 WC 7-WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD 29-02-001 �.0` -1-5-156/22/04 V <br />